Active NPI
Michael J Wine, DDS
- Dentist
- Jackson, WY
National Provider Identifier
1245353168
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Dentist
- License
- 1325
- Practice address
- 610 W Broadway Ave
Jackson, WY 83001-8213 - Phone
- (307) 732-2273
- Fax
- (307) 732-1660
- NPI assigned
- Apr 7, 2007
- Last updated
- Sep 1, 2016
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 2
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Dentist | 122300000X | 1325 | WY | Primary |
| Dentist | 122300000X | D 4424 | ID |
Addresses
Primary practice location
610 W Broadway Ave
Jackson, WY 83001-8213
Mailing address
6797 Shire Ridge Dr
Victor, ID 83455-5036
Phone (614) 648-6657
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| D 4424 | ID | MD | Dentist |
| 1325 | WY | MD | Speech-Language Pathologist |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| RJ Smiles, LLC | Dentist | Past | Accepting new patients |
Organizations & group practices 1
Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1175904000000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1472688000000",
"number": "1245353168",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "6797 SHIRE RIDGE DR",
"city": "VICTOR",
"state": "ID",
"postal_code": "834555036",
"telephone_number": "614-648-6657"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "610 W BROADWAY AVE",
"city": "JACKSON",
"state": "WY",
"postal_code": "830018213",
"telephone_number": "307-732-2273",
"fax_number": "307-732-1660"
}
],
"practiceLocations": [],
"basic": {
"last_name": "WINE",
"first_name": "MICHAEL",
"middle_name": "J",
"name_prefix": "Dr.",
"credential": "DDS",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2007-04-07",
"last_updated": "2016-09-01",
"status": "A"
},
"taxonomies": [
{
"code": "122300000X",
"taxonomy_group": "",
"desc": "Dentist",
"state": "WY",
"license": "1325",
"primary": true
},
{
"code": "122300000X",
"taxonomy_group": "",
"desc": "Dentist",
"state": "ID",
"license": "D 4424",
"primary": false
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Jackson, WY
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 1, 2016; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.